Provider Demographics
NPI:1205499910
Name:SPARKS, LAUREN NICOLE (DO)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 675398
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-5398
Mailing Address - Country:US
Mailing Address - Phone:586-329-1880
Mailing Address - Fax:586-231-0055
Practice Address - Street 1:30795 23 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-5721
Practice Address - Country:US
Practice Address - Phone:586-421-1600
Practice Address - Fax:586-421-2002
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY05240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1205499910Medicaid
MIMI16311021OtherMEDICARE HFPP